Excellence in palliative care is a priority in the nursing home (NH) setting, which provides care to many older residents with advanced illness at the end of life. Unfortunately, suboptimal palliative care is common. Infections are a frequent occurrence and management is challenging for many reasons. In our successful parent study we focused on infection control and management programs in NHs across the nation and found that annually 40% of all Medicare-certified NHs receive deficiency citations for inadequate infection control and less than half of NHs (46%) had written guidelines for antibiotic initiation. Antibiotics account for approximately 40% of all medications administered in NHs. Unfortunately, much of the use is inappropriate as antibiotics are often initiated in the absence of clinical evidence of a bacterial infection, and this misuse is a major risk factor for multidrug-resistant organisms and Clostridium difficile infections. Suspected infections are common reasons for elderly resident transfers to hospitals, and these are burdensome and often not clinically beneficial. For the majority of NH residents, the risks and suffering associated with antibiotic use and hospital transfer due to infection may outweigh the benefit.In addition, the infection control and management as well as the palliative care landscapes are changing in NHs with various regional and state level initiatives being implemented. It is likely that for some NHs these initiatives will promote resident-centered care that integrates infection management and palliative care while in others, NH personnel will be held to standards that favor burdensome curative treatments. In our competing renewal, we will use longitudinal Minimum Data Set data and Medicare files (i.e., approximately 1 million residents over years 2011 to 2017) to identify elderly NH residents and important resident level covariates (e.g., advanced illness), track antibiotic and hospice use, and track hospital transfers related to infections.We will complement and link these secondary datasets with environmental scans of state and regional activities as well as with data from a national survey of new NHs and our ?core? NHs surveyed in 2014 as part of our parent study (we estimate that 1,500 NHs will respond). The survey will characterize implementation of current recommended structures and processes related to: 1) infection control and management, 2) palliative care, and 3) the integration of infection management and palliative care. Our specific aims are to:1) Describe the integration of infection management and palliative care in NHs and the associated facility, state, and regional characteristics; 2) Examine factors associated with antibiotic use in elderly NH residents; and 3) Examine factors associated with hospital transfer due to infections among elderly NH residents. Understanding how best to improve the integration of infection management and palliative care to improve residents' quality of life is an under-studied area in need of rigorous research. Thus, this innovative study has the potential to make clinical and policy-relevant contributions by promoting resident-centered end- of-life care for millions of Americans living in NHs.